Qui Tam Contact Form

(Note: Do not discuss your complaint with anyone else, in order to preserve your right to bring a suit. If you are bringing a complaint against your current employer, it is strongly recommended that you do not fax or e-mail this form from your place of employment)

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

Name of person and/or company engaged in the fraud

Address

Name of person responsible, if known

What is your relationship to this person or company

Agency or program defrauded

Please provide a detailed description of the fraud

How did you learn of the fraud

Were you involved in the fraud
Yes  No 

If yes, how were you involved

Approximately how much money was involved

How did you first learn of the fraud

Have you reported the fraud to the person or company involved
Yes  No 

If yes, list the name of the person you reported to, and the result of your report

If you are an employee of the person or company involved, has any action been taken against you after your report
Yes  No 

If so, describe the action taken

Have you reported this fraud to any governmental or law enforcement agency
Yes  No 

If so, list the name of the agency , the contact person at the agency, and give a summary of what you discussed with them

Have you discussed the fraud with anybody else
Yes  No 

If so, who did you discuss it with and what did you tell them

Is there anyone else who knows about the fraud
Yes  No 

If yes, provide names and contact information if known

Do you have any documents regarding the fraud
Yes  No 

If so, provide a description of those documents

Were you referred by somebody else
Yes  No 

Who

Special concerns

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